ED Coding and Reimbursement Alert

Question: A patient reports with a severe headache and blurred vision. During the course of an E/M service, the physician prescribes pain medication for the patient. Suspecting a migraine, the physician recommends the patient undergo a computed tomography (CT) scan. The patient refuses the CT scan, saying she-d prefer to try to -get by- with the pain medication. When determining the E/M level for this service, should I give the physician credit for the CT scan order?


Iowa Subscriber

Answer: You can factor the physician's order into the medical decision-making--but make sure he documented:

- that he ordered the test
- that the patient refused the test
- why the patient refused the test.

Also, factor the physician's decision to run a CT scan into your E/M level, because the physician made a medical decision to run the test--even though the patient ultimately declined the service.